Scandinavian Journal of Primary Health Care

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The management of chronic neck pain in general

practice: A retrospective study

Jeroen Borghouts, Henriëtte Janssen, Bart Koes, Jean Muris, Job

Metsemakers, Lex Bouter

To cite this article: Jeroen Borghouts, Henriëtte Janssen, Bart Koes, Jean Muris, Job
Metsemakers, Lex Bouter (1999) The management of chronic neck pain in general practice:
A retrospective study, Scandinavian Journal of Primary Health Care, 17:4, 215-220, DOI:
10.1080/028134399750002430

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The management of chronic neck pain in general
practice
A retrospecti6e study
Jeroen Borghouts1, Henriëtte Janssen2, Bart Koes1, Jean Muris2, Job Metsemakers2 and
Lex Bouter1,3
1
Institute for Research in Extramural Medicine (EMGO), Vrije Universiteit, Amsterdam, 2Department of General
Practice (Research Institute ExTra), Maastricht University, 3Department of Epidemiology and Biostatistics, Vrije
Universiteit, Amsterdam, the Netherlands
Received November 1998. Accepted February 1999.
Scand J Prim Health Care 1999;17:215–220. ISSN 0281-3432
Objecti7e – To describe the management in patients with chronic
non-specific neck pain in general practice.
Design – A descriptive, questionnaire-based retrospective study.
Setting – General practices in the Netherlands.
Patients – 517 patients with chronic non-specific neck pain.
Main outcome measures – Nature and frequency of diagnostic proce-
dures, therapeutic interventions and referrals by the general practi-
tioner (GP).
Results – Forty-four per cent visited the GP for neck pain in the
previous year. Of the patients who did visit the GP in the previous
year, 32% did not receive a diagnostic modality, 31% did not receive
therapy and 43% were not referred. The most frequently applied
diagnostic and therapeutic modalities were physical examination
Musculoskeletal disorders are a major cause of mor-
bidity and disability in Western societies. A substan-
tial part of the musculoskeletal disorders constitutes
neck pain. Point prevalences are reported in the range
of 9.5%–35% (1 – 3), although the majority of the
prevalences are ranging from 10% to 15% in these
studies. A lifetime prevalence of 43% was reported
for woman in the age group 50 – 59 years (4). The
prevalence of chronic neck pain, drawn from the
National register of Norway, was reported to be 14%
(5). About the same prevalence was found in a popu-
lation-based study in Finland, in which ‘‘Chronic
neck syndrome’’ was identified in 10% of males and
14% of females (1).
In general practice the prevalence of neck pain has
been estimated as 18 per 1000 registered patients per
year (6). The complaints usually are not regarded as
life-threatening, but the patients endure pain and/or
stiffness which may affect their physical and social
functioning considerably. Neck pain is often a cause
for work absence. In some industries it even accounts
for as many absences as low-back pain (7). The pain
may arise from any of the structures in the neck.
ORIGINAL PAPER
(66%) and pain medication (58%), respectively. The GPs most
frequently referred to a physiotherapist (51%).
Conclusion – Once neck pain has become chronic, the minority
(44%) of patients do seek help from their GP on a yearly base. In
spite of the fact that the patients’ conditions are non-specific and
chronic, GPs still find indications for further diagnostics in two-thirds
of patients. The GPs were rather consistent in their management, as
the nature of the diagnostic/therapeutic modalities and referrals was
similar in more than 50% of the patients.
Key words: general practice, neck, pain, management.
Jeroen Borghouts, MSc, PT, Institute for Research in Extramural
Medicine (EMGO-Institute), Faculty of Medicine, Vrije Uni7ersiteit,
Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.
These include the intervertebral discs and annuli,
ligaments, muscles, facet joints, dura and nerve roots
(8). There are a large number of potential (specific)
causes of neck pain. These vary from trauma (espe-
cially motor vehicle accidents), infections, tumours,
congenital disorders and inflammation. In the large
majority of cases, however, no specific underlying
pathology can be established and the complaints are
labelled as non-specific neck pain. In these cases
radiologic abnormalities are usually not found or
occur in the same frequency as among subjects with-
out complaints (9).
The evidence for or against the efficacy of thera-
peutic interventions for neck pain is largely lacking
(10,11). Possibly as a consequence of this situation
general practitioners (GPs) seem to show a large
variety regarding the management of neck pain (12).
In general, there is a broad spectrum of diagnostic
procedures available for neck pain patients: plane
radiographs, tomography, computed tomography
(CT) scans, magnetic resonance imaging (MRI), elec-
tro myogram (EMG), etc (10). The same holds true
for the availability of therapeutic interventions for
neck pain.
Scand J Prim Health Care 1999; 17
216 J. Borghouts et al.
Little is known about which (and to what extent)
diagnostic procedures and therapeutic interventions
are applied to patients, especially in the situation that
their complaints do not disappear within a few weeks
and thus become chronic. In the literature pain is
often classified as acute (0 – 6 weeks), sub-acute (6
weeks–3 months) and chronic ( \3 months) (13).
Therefore, the aim of this study was to describe the
nature and frequency of diagnostic procedures and
therapeutic interventions in patients with chronic
non-specific neck pain in general practice.
MATERIAL AND METHODS
Registration network family practices
Information for this study was generated from GPs
and their patients. The GPs who participated in this
study were recruited from the Registration Network
of Family Practices (RNH) of the University of
Maastricht in the Netherlands (14). The Registration
Network has been set up as a sampling frame for
research and educational programmes. Health prob-
lems are only recorded by the GPs if they are perma-
nent (no recovery expected), chronic (duration longer
than 6 months), or recurrent (more than three recur-
rences within 6 months). All health problems are
coded according to the International Classification of
Primary Care (ICPC) (15).
The patient population registered in the RNH
reflects the Dutch general population and data on
health problems and diagnoses were shown to be
valid and reliable (14).
Patient sample
A sample of 709 patients was taken from the RNH
database. Potentially eligible patients were identified
using two relevant ICPC-codes (L01, L83). The pa-
tients were registered with a total of 33 GPs, who
worked in 17 practices. The medical records of all
identified patients were carefully checked by the GPs
on inclusion and exclusion criteria. Patients were
included in our study based on the following criteria:
1) L01: neck symptoms/complaints (excluding
headache) or L83: syndromes of cervical spine, 2) age
18–70 years, 3) symptoms had to be present for at
least 6 months before baseline. The GPs excluded
patients if the neck pain could be explained by spe-
cific underlying pathology such as: tumours, frac-
tures, infection, inflammatory disorders (e.g.
rheumatoid arthritis) and osteoporosis.
Procedure
All selected patients were sent a self-administered
questionnaire, covering a 12-month period and a
letter of introduction by their GP, in order to guaran-
Scand J Prim Health Care 1999; 17
tee the privacy of non-responders. If patients did not
respond within 2 weeks, they received a reminder
from their GP. The GPs were asked to check their
medical records and to fill out questionnaires for
both responders and non-responders regarding nature
and frequency of the procedures. Before the start of
the study two GPs stated they were willing to fill out
questionnaires for a random sample of patients only,
because of a lack of time.
Questionnaires
The GPs’ questionnaire contained items concerning
diagnosis, frequency of GP visits, diagnostic modali-
ties, therapeutic interventions and referrals to medical
specialists or paramedical therapists. The patients’
questionnaire contained items regarding patient char-
acteristics, pain intensity, sickness related to work
and visits to medical specialists/paramedical thera-
pists. Information on the onset and frequency of pain
episodes during the previous 12 months was ob-
tained. The severity of the current pain (pain during
the last week) was measured on an 11-point ordinal
scale, ranging from 0 (no pain) to 10 (unbearable
pain).
Statistics
Descriptive statistics were used to present the fre-
quencies of diagnostic and therapeutic interventions
and referrals. Patient characteristics were described
by median and quartiles since most of the variables
were asymmetrically distributed. Differences in pa-
tients characteristics between responders and non-re-
sponders were assessed by a Mann–Whitney U test.
The difference in mean age was assessed by a t-test.
Comparison of sex in both groups was made by
means of a chi-square test.
RESULTS
Patient sample
Initially a sample of 709 patients was taken from the
RNH database (Fig. 1.). Thirty-eight patients were
excluded because they had symptoms for less than 6
months and 111 patients were under 18 or over 70
years of age. Due to a lack of time, two GPs filled out
questionnaires for only a random sample of patients.
Therefore, another 43 patients were excluded, making
a total of 517 eligible patients. Of these 517 patients,
281 (54%) returned the questionnaire. To confirm a
correct selection, the investigators checked the re-
turned questionnaires and excluded another 15 pa-
tients. Nine patients reported to have had no neck
pain in the previous year and six patients were under
18 or over 70 years of age. This made a total of 266
responding patients.

GPs were asked to fill out questionnaires for all
502 included patients. The GPs returned 487 (97%)
questionnaires (regarding 253 responders and 234
non-responders). For 11 patients no questionnaire
Fig. 1. a) Flowchart of the study (patients).
b) Flowchart of the study (GPs).
The management of chronic neck pain in general practice 217
was returned because the GPs detected they had
classified their patients by an incorrect ICPC-code
initially. Four questionnaires were not returned with-
out a given reason.
Patient characteristics
The responders and non-responders were compared
for demographic and descriptive characteristics
(Table I).
The mean age for the responders was 50 years
(median 51). The mean severity of pain was 4.9 (SD
2.4). Sixty per cent of the responders appeared to be
women. Twenty-four per cent had private insurance
and 76% had public insurance. Classification accord-
ing to education showed that 57% were classified as
unskilled or lower class, 31% as middle class and 12%
as higher class personnel. Forty-nine per cent of the
responders were employed during the previous year.
Of the 49% who had been employed during the
previous year, 13% reported absenteeism for less than
1 week and 20% had been absent from work for more
than 1 week due to neck pain. Eighty-six per cent of
the responders reported neck pain radiating towards
other parts of the body. In 66% the pain radiated
towards the head. In 30% the pain radiated below the
elbow, which could indicate neurologic abnormalities.
Nine per cent reported the pain only to be located
outside the neck area, with the primary cause of the
pain localised in one of the neck structures. Accord-
ing to 18% of the responders, the cause of their
symptoms was unknown. The most frequently re-
ported causes were ascribed to working conditions
(29%), tension/stress (29%) and a poor posture (21%).
Diagnosis, therapy and referrals
During the previous year, 56% of our cohort did not
visit their GP for neck pain. Twenty-three per cent
visited their GP for neck pain (being their main
complaint) once and 21% visited their GP two or
more times. The frequencies of the different modali-
ties and referrals are reported for the total cohort and
for the number of patients who visited their GP at
least once for neck pain in the previous year (Tables
II, III and IV).
The frequencies of the different diagnostic modali-
ties used by the GPs are reported in Table II. Of the
patients who did visit their GP in the previous year,
32% did not receive a diagnostic modality. Sixty-six
per cent of all diagnostic modalities consisted of
physical examination.
The therapeutic modalities advised or applied by
the GPs are reported in Table III. Of the patients
who did visit their GP in the previous year, 31% did
not receive therapy. Fifty-eight per cent of all advised
or applied therapeutic modalities consisted of pain
medication, including NSAIDs.
Scand J Prim Health Care 1999; 17
218 J. Borghouts et al.

Table I. Comparison of demographic and descriptive characteristics for responding and non-responding patients (reported by
GPs).

Responders (n = 253) Non-responders (n = 234) p-value2

Median (Q1–Q3)1 Median (Q1–Q3)1

Age 51 (41–60) 55 (44–62) 0.006

First onset of pain ever (years ago) 5 (2–8) 6 (3–9) 0.011
GP visits previous year (all diagnosis) 5 (2–8) 4 (2–8) 0.461
GP visits previous year (neck) 0 (0–1) 0 (0–1) 0.017
Sex
Male (%) 40 44
Female (%) 60 56 0.411
1
Q1 = first quartile, Q3 =third quartile.
2
Differences in patient characteristics between responders and non-responders.

Table II. Diagnostic modalities used in patients with chronic non-specific neck pain in general practice during the previous year
(reported by GPs).

Patients with GP Total population

consultation (n =212) (n= 487)

n1 %2 n1 %2

No diagnostic modalities 69 32 325 69

Physical examination 137 66 137 28
Laboratory examinations 14 7 14 3
X-ray 28 14 28 6
Other imaging techniques: 4 2 4 B1
CT, MRI, myelography, discography
1
Note that this number refers to the number of patients that received a diagnostic modality and does not indicate the total number
of procedures.
2
Note that the total is more than 100% because several modalities could be applied to one patient.

Table IV reports on visits/referrals. Of the patients
who did visit their GP in the previous year, 43% were
not referred. The GPs most frequently referred to a
physiotherapist (51%).
DISCUSSION
The information we used could be divided in two
parts. First, there is the information on diagnostic
procedures, therapy and referrals. This information
was obtained from the questionnaires the GPs filled
out and returned in 97% of the cases. This means we
had almost 100% coverage of the data the research
question was based upon. Because the aim of this
study was to give an insight into the management by
the GPs these data provide reliable information. Sec-
ond, there is information on the nature of complaints
which was used additionally. This information was
obtained from the questionnaires the patients filled
out and returned in 54% of the cases. The significant
differences between responders and non-responders
do not affect the validity of the information on the
management, since this information was provided by
the GPs for both responders and non-responders.
Information on the nature of complaints could be
biased, although the differences were very small from
a clinical point of view.
There appeared to be a substantial discrepancy
between the number of visits to a medical specialist
or paramedical therapist, reported by the responders
and the numbers of referrals as reported by the GPs.
Part of the difference in reporting can be explained
by the fact that medical specialists are also allowed to
refer. For example, of patients who received treat-
ment by a physiotherapist between 1989 and 1992 in
the Netherlands 16% were referred by a medical
specialist (16). Eighty-one per cent were referred by
the GP. Van Tulder et al. (17) found similar dis-
crepancies between patients and GPs in their
reporting.
In general, about 56% of the patients with chronic
non-specific neck pain did not visit the GP in the
previous year. This high percentage may be caused by
the fact that the patients already received some form
of examination or treatment at the beginning of their
medical career. Studying the acute phase is not possi-
ble in this cohort since you would need an inception
cohort. Another possibility would be to reveal retro-

Scand J Prim Health Care 1999; 17

 The management of chronic neck pain in general practice 219

Table III. Therapeutic modalities advised or applied by the GPs in patients with chronic non-specific neck pain in general practice
during the previous year (reported by GPs).

Patients with GP consultation Total population

(n =212) (n =487)

n1 %2 n1 %2

No therapy 65 31 310 67
Heat application 39 20 39 8
Rest 22 11 22 5
Medication
Paracetamol, aspirin/NSAIDs 120 58 120 26
Benzodiazepines 23 10 23 5
Antidepressants 7 3 7 2
Other medication 16 8 16 3
Postural advice 35 18 35 8
Collar 7 3 7 2
Other: ointment, injection, orthopaedic pillow 6 3 6 1
1
Note that this number refers to the number of patients that received a therapeutic and does not indicate the total number of
procedures.
2
Note that the total is more than 100% because several modalities could be applied to one patient.

Table IV. Visits/referrals to medical specialists and paramedical therapists in patients with chronic non-specific neck pain in general
practice during the previous year (reported by participating patients and GPs).

Patients General practitioners

Responders1 Responders2 Total Patients with GP

(n= 266) (n =253) population3 consultation
(n= 487) (n=212)
%4 %4 %4 %4

No referral 33 65 72 43
Physiotherapist 47 26 22 51
Manual therapist 14 5 4 8
Chiropractor 6 1 B1 1
Mensendieck therapist5 6 1 1 2
Cesar therapist5 2 2 1 3
Orthopaedic surgeon 5 3 2 5
Neurologist/neurologic surgeon 9 6 4 8
Rheumatologist 3 1 B1 1
Homeopathist 3 0 0 0
Acupuncturist 2 0 0 0
Other: haptonomist, neck/back-school, 1 0 0 0
anthroposophist, rehabilitation specialist,
psychologist, magnetizer
1
Percentages of visits to medical specialists and paramedical therapists the previous year, reported by the responding patients.
2
Percentages of referrals to medical specialists and paramedical therapists the previous year, reported by GPs on the responding
patients.
3
Percentages of referrals to medical specialists and paramedical therapists the previous year, reported by GPs on the responding
and non-responding patients.
4
Note that the total is more than 100% because patients could be referred to several (para)medical services.
5
Posture correction and exercise therapy.

spectively what happened in the acute phase. Since
the first episodes of the neck pain were reported in
general more than 5 years ago, this would probably
lead to recall bias. Compared to the study of Van
Tulder et al. (17) some differences in the number of
GP visits between patients with neck pain (44%) and
low-back pain (80%) appeared. The difference in the
number of visits may indicate that neck pain patients
experience their pain as a lesser burden or are able to
manage their pain, resulting in less frequent GP
visits. As for the management of patients who did
visit the GP for neck pain, the GP was rather consis-

Scand J Prim Health Care 1999; 17

220 J. Borghouts et al.
tent, as the nature of the diagnostic/therapeutic
modalities and referrals was similar in more than 50%
of the patients. Some differences in the management
of the total cohort of neck pain versus low-back pain
were apparent, e.g., the discrepancy between neck
and low-back patients regarding X-rays. Perhaps the
frequency of using imaging techniques in patients
with neck pain compared to low-back pain is likely to
be lower because the incidence of herniated cervical
discs (5.5/100000/year) is much lower than the inci-
dence of herniated lumbar discs (5/1000/year) (18).
This study showed that once non-specific neck pain
has become chronic, only 44% of the patients seek
help from their GP on a yearly base. In spite of the
fact that the patients’ conditions are non-specific and
chronic, GPs still find indications for further diagnos-
tics in two-thirds of the patients. About one-third did
not receive a therapeutic modality and one-third were
not referred. Although the management of the GPs
seems to be rather consistent, this descriptive study
itself can not reveal the quality of the management by
the GPs.
Since this study used prevalent chronic cases, no
information could be obtained on acute patients.
Therefore, future studies should use incident cases to
compare acute and chronic patients regarding the
proportion of patients visiting their GP and the man-
agement by the GP. The use of incident cases can
also be useful in identifying factors associated with
acute neck pain patients, predestined to become
chronic.
ACKNOWLEDGEMENTS
This study was conducted at the Institute for Re-
search in Extramural Medicine, Vrije Universiteit,
Amsterdam, the Netherlands, in collaboration with
the Registration Network Family Practices (RNH),
Universiteit Maastricht, The Netherlands. The study
was supported by a grant from the Dutch Organisa-
tion for Scientific Research (NWO), The Hague, The
Netherlands. The authors wish to thank Ms DLM
Veldman for her assistance on the management of the
data and the preparation of the manuscript.
Scand J Prim Health Care 1999; 17
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